Clinical introduction A 59-year-old male patient presented with acute onset shortness of breath and intermittent chest pain. His medical history included squamous cell carcinoma of the left upper lobe of the lung (tumour, node, metastases T3N2M0), which was treated with radical radiotherapy with concurrent vinorelbine/cisplatin chemotherapy 6 months ago, hypertension, type 2 diabetes mellitus and hypercholesterolaemia. A 12-lead ECG on arrival is shown in figure 1A which has led to the patient undergoing emergency coronary angiography (figure 1B and online supplementary video). Admission blood tests revealed troponin T levels of 17 (0–14) ng/L, and an echocardiogram showed an akinetic basal septum and a hypokinetic basal–mid lateral anterior wall and apex. The next day, the patient underwent a functional and gadolinium-enhanced cardiovascular MRI (figure 1C,D).

Question What is the most likely cause of this patient’s symptoms?

1. ST-elevation myocardial infarction (STEMI) of the lateral wall.

2. Compression of left circumflex artery due to metastatic disease.

3. Acute pericarditis.

4. Takotsubo syndrome.

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Figure 1

(A) Admission ECG, (B) coronary angiogram and (C,D) four-chamber view of cardiac MRI.